Hygiene from antiquity to the present day

In ancient times, we already find advanced conditions. In pre-Christian Rome and Athens, for instance, the fresh water supply, bathhouses, and even sewage systems were part of the infrastructure. Bathing in public bathhouses in the 5th century BC, when there were no private bathing rooms, served primarily as purification but also to maintain health and well-being. A great bathing culture developed, which also had an important social function. People met, washed, and made love. Massages, cosmetic treatments, and even minor surgeries were commonplace. Business deals were also made in the bathhouses.

Even when it came to toilets, we find evidence of advanced conditions. The ruins of some Iraqi palaces, for example, have flush toilets. In Greece, archaeologists have discovered richly decorated toilet rooms. Archaeological finds of toilets from over 5000 years in age have been found in Scotland, India, Italy, Greece and Iraq – essentially, all over the world. (1,2,3)

Due to their partially advanced standards, however, the general hygienic conditions of antiquity are often glorified today – at least as far as the vast majority of societies are concerned. In fact, however, the world of Plato and Augustus was anything but clean. Most people lived closely with their animals; their toilets were often located next to the kitchens to stay warm, and since there was no waste collection in today’s sense, the streets were often full of garbage.

In addition, because toilet paper was not developed until much later, people often cleaned with sponges or their hands after relieving themselves. One sponge per toilet was often shared with several inhabitants, which was not particularly hygienic.

People in ancient cities such as Rome were to some extent already thinking about how to transport human waste out of the cities via rivers or simple sewer systems. Depending on the weather, however, this led to new problems. During floods, for example, everything resurfaced. During droughts, the rivers turned into stinking broths that hardly flowed at all. The final destination for faecal matter was often meadows and fields. Drinking water was also often polluted and contaminated with bacteria and germs. When the plague broke out in Athens in 430 BC, about a quarter of the population died of it. After the fall of the Roman Empire in the 5th century BC, the toilet culture was abandoned. (4,5,6)

Stinking garbage in the streets and faeces dumped out of windows, animals running loose and muddy paths: there’s a reason the Middle Ages are considered dirty. Unsurprisingly, the plague – a disease transmitted from rats to humans via flea bites – broke out in 1347. The epidemic spread easily due to three factors: people did not know about bacteria and viruses, hygienic conditions were miserable, and in addition, they believed that the plague was caused by polluted water and thus, washed less. A vicious circle.

Over a period of a few years, the plague killed about a third of all Europeans in three waves. Exact figures are not available, but around 20 to 50 million people are estimated to have died. Entire villages were wiped out. The highly contagious epidemic could only be contained by isolating the sick and through quarantine measures. The first laws on “keeping streets clean” were also passed at this time to improve hygienic conditions. However, it was not until 1894 that the Swiss physician Alexandre Yersin discovered the plague pathogen. (7)

At the beginning of the 18th century, people came up with a rather unusual method of protecting themselves from disease: They tried to close their pores with powder and perfume. Cleaning oneself with water was frowned upon, because people still believed that the plague was transmitted by contaminated water. Thus, until the 19th century, there were no water flushes even in castles. Instead of cleaning themselves, people preferred to perfume and powder themselves. In those days, this extensive procedure was called a “toilet”, but had little to do with what we understand by that word today. A “number one” or “number two” was done in the alleys, behind bushes, or even in house corridors.

Until the first half of the 19th century, science still considered cleanliness and disinfection to be of secondary or no importance in medicine. Unwashed hands and instruments in hospitals therefore allowed germs to spread unhindered, and as a result, blood poisoning and childbed fever were common causes of patient death. (8,9)

In the mid-19th century, nearly one in two patients died of wound fever (blood poisoning) during or after surgical procedures. Medical instruments and surgical aprons were not cleaned regularly and doctors did not often wash their hands. This did not change until Ignaz Semmelweis, while working at the General Infirmary in Vienna in 1846, discovered that a major reason for frequent deaths after surgical procedures was the lack of hand disinfection. Specifically, he discovered that mothers died significantly more often after childbirth when examined by physicians who had previously dissected corpses than when examined by midwives who had not previously handled bodies.

Semmelweis correctly concluded that the doctors were transferring dangerous pathogens from the corpses to the patients. He therefore introduced washing with chlorinated lime. Within two months, mortality on the ward dropped from 17 to 1.2 percent. Unfortunately, Semmelweis’s discoveries did not spread in medical circles for a long time, which is why doctors at the time continued to work in hospitals without disinfection. For many years, Semmelweis fought to implement hand hygiene before medical interventions, unfortunately in vain. He ultimately ended up in a hospital due to severe depression. The circumstances of his death there – allegedly sepsis – have never been fully clarified. (10)

The importance of hygiene only became more significant in the second half of the 19th century, thanks in part to Max von Pettenkofer. The young chemist studied pharmacy, chemistry, and medicine in Munich, earned a doctorate in surgery and additionally licensed as a pharmacist. With his extensive education, he was appointed professor of medicinal chemistry at the LMU Munich in 1847. In the same year, he was also awarded the professorship of hygiene in Germany.

Pettenkofer soon put his expertise to use, when cholera broke out a few years later in Munich. The young chemist quickly became aware of the poor hygienic conditions in the city. At the time, Munich had no running drinking water, garbage littered the streets and faeces were simply collected in large squares. Pettenkofer realized that the hygienic conditions in the city and the health of its inhabitants were interrelated and turned hygiene into a science. His studies and efforts to improve Munich’s urban hygiene first met with resistance, but they quickly had an effect. Thus, the stinking juggernaut that was Munich became a hygienic metropolis with sewage systems and hygiene plans.

In 1883, Pettenkofer was awarded the title “von” Pettenkofer for his achievements. He ensured that by 1900, almost 80 percent of Munich’s population was connected to the sewer system. At last, knowledge of hygiene gained ground and eventually made itself felt throughout Europe. (11)

In the 1870s, several physicians simultaneously became crucial to the development of hygiene. They all built on the knowledge of each other: Robert Koch, Louis Pasteur, and Joseph Lister.

Robert Koch discovered the tuberculosis pathogen, played a key role in containing a cholera outbreak in Hamburg, and found other pathogens such as those of malaria, and sleeping sickness. In 1891, he became director of the Berlin Institute for Infectious Diseases, which was later named after him. Koch received the Nobel Prize for his research on tuberculosis and, along with his Parisian colleague Louis Pasteur, was one of the founders of modern bacteriology and microbiology as well as immunology and allergology. (12,13,14)

Around the same time as his German colleague, Louis Pasteur was researching microorganisms produced by putrefaction and fermentation and found that certain foods, such as milk, could be preserved by heating. This gave rise to the process we now call “pasteurization”. In addition, Pasteur developed the first laboratory-produced vaccine against fowl cholera and later a successful vaccine against anthrax. (15,16)

Building on Pasteur’s discoveries, Joseph Lister in Scotland experimented with a phenol-based antiseptic, developing the basis for sterility. The use of rubber gloves, frequent hand washing by physicians, and the disinfection of hands, instruments, and dressings with phenol rapidly reduced patient mortality. (17)

We owe another important medical milestone to coincidence. When bacteriologist Alexander Fleming returned to his laboratory from his summer vacation in 1939, he was astonished. An unwashed Petri dish in which he had experimented with bacteria before leaving was full of green mould. These mould had completely destroyed the bacteria. He succeeded in extracting the bacteria-killing substance and named it penicillin. The first antibiotic was born.

Fleming’s discovery is considered another breakthrough in medicine. His publications did not attract attention at first, but during World War II he became world famous and penicillin became a true miracle cure. Fleming, who received the Nobel Prize for his work, also showed foresight when he predicted as early as 1945 that antibiotics could lose their effectiveness if they were not used responsibly. He proved to be right, as widespread use in factory farming and medical professionals who often prescribed them needlessly have led to fight antibiotic-resistant germs. Nevertheless, antibiotics are still indispensable in today’s medicine. (18)

The groundbreaking discoveries of previous researchers and physicians paved the way for the development of marketable disinfectants as we now know them. Until the 1960s, doctors laboriously disinfected their hands using a solution containing formalin. However, this procedure had two disadvantages – it was damaging to the skin and the hands did not remain sterile for long. That is why, in 1965, the Bode Chemie research team, in collaboration with doctors, developed the first marketable, alcoholic hand disinfectant: Sterillium®.

The fast-acting alcohol-based solution, Sterillium® Virugard, secured a place on the Robert Koch Institute's list of tested and approved disinfectants in 1995 as the first highly effective virucide. In 2005, Sterillium® was also the first hand disinfectant in the medical sector to receive approval for surgical hand disinfection with reduced exposure time from 3 to 1.5 minutes. (19,20,21,22)

The caring properties of Sterillium® products have been of high importance since their introduction. The hands are the surgeons' main tool, so it is particularly important that they are healthy. In 2022, the ZEIT publishing group named Sterillium® “Brand of the Century” for the third time. (23)

The history of hygiene is long and constantly evolving, yet today we are at an unprecedented level. By being able to disinfect hospitals, medical instruments, and wounds as well as our hands, we protect doctors and patients. This is especially important for those with compromised immune systems. Although disinfectants have made life easier for many people, their development is not over yet. An important task for the future will be to further improve hygiene conditions worldwide and, above all, to create better conditions in the global south so that people have access to running water, toilets, and disinfectants.